Draft Project Charter Eliminating HAI's - Patientsafetycouncil.org

Project Title:
Sponsor:
Draft Project Charter
Eliminating HAI’s
December 2010
Eliminating HAI’s (specifically targeted: VAP, CLABSI, CAUTI).
Hospital Association of San Diego & Imperial Counties/Anthem Blue Cross
Process Owner: Hospital, Infectious Disease
Facilitator:
Cynthia Cadwell MS
Start Date: 16 February 2011 End Date: 31 December 2011
Problem Statement: 1.7 million HAI’s occur each year in the USA and kill 99,000 patients. In San
Diego County acute care facilities, approximately …. patients die on a daily basis in due to HAI’s.
Team Members:
• Alvarado Hospital
• El Centro Regional MC
• Fallbrook Hospital
• Hospital Association of San Diego & Imperial
Counties
• Naval Medical Center San Diego
• Palomar Pomerado Health
• Paradise Valley Hospital
• Pioneers Memorial Hospital
• Rady Children’s Hospital San Diego
• Scripps Health
• Sharp HealthCare
• Tri-City Medical Center
• UCSD Medical Center
• VA Healthcare San Diego
Project Scope:
This project includes the following acute care
inpatient population admitted to any hospital
units:
May start with ICU’s (per type of HAI)
and progress to other units as
convenient for facility
May use house-wide data per
department as currently collected
• Adult/Geriatrics
• Pediatrics (and note differences)
• Multiple Co-morbidities
• Not Present on Admission infections
• Neonates
• Dialysis patients
This project excludes:
• individuals on hospice or comfort care
• on specialized units for immune-suppressed
patients
• Oncology-neutropenic
• Bone Marrow Transplant
Deliverables:
• Best practice and guidelines of care
• Surveillance tool(s) – to evaluate for both
effective treatments and infection outbreaks
• Order sets
• Implementation plans
• Education on process / algorithms / bundles
• Definitions – based on best practice
• Data gathering assistance
• Elevator speech
• Outcomes and tools to measure outcomes
Goal and Other Potential Benefits:
To develop evidenced-based project tools and
organization-specific measures to reduce the
occurrence and mortality of preventable HAI in
the hospitalized patient to (near) zero across the
county. Furthermore, focused preventative
measures for hospitalized patient will reduce the
morbidity, mortality and healthcare costs
associated with these HAI’s.
Customer(s) and Requirements:
Health care professionals need straightforward protocols that can be consistently executed and
change acceleration strategies to improve adoption of best practices.

Population
Preventing HAI’s can reduce patient progressing to morbidity, increased LOS and death
Coding based on MD diagnosis HAI (use any available codes for VAP, CLABSI & CAUTI)
C Diff may an HAI of interest to ‘further’ target
Dioalysis patients may be a target that could have significant benefit
• Most MDs identify infection but not necessarily HA
• Providers not aware of documenting POA infections
• Patient admitted into hospital without infection?
• N = all patients with ‘preventable’ HAI (VAP, CLABSI, CAUTI)
• D = device days/1000 (as per NHSN standard reporting)
Goal
• Reduce the incidence of HAI’s in the acute care patient to near zero across the county;
• Need current number – administrative data – for Not Present on Admission
• Side goal: Reduce costs and LOS for patients requiring certain devices.
• Each organization: rate of VAP, CLABSI, CAUTI not POA
How can this project help us at our facility?
• Implementation tools, ideas and methods sharing can accelerate change and impact
Elevator Speech
Recommend producing an elevator speech for each target audience.
• What our project is about… prevention of the HAI’s (VAP, CLABSI & CAUTI and/or C Diff) to near zero in
our region, as well as improving overall patient outcomes.
• Why it is important to do… because HAI’s are preventable with appropriate intervention, yet today it
occurs in about 1.7million per year in the US, killing 99K. That’s …. patients getting HAI’s in our region per
day, and … dying from them.
• What success will look like… increased regional compliance with evidenced-based best practices
resulting in zero ‘preventable’ HAI’s, and institutions realizing an overall decrease in patient hospital stay
and costs.
• What we need from you… a commitment to understand, support, and comply with best practices to
prevent HAI’s including early identification of high-risk patients, collaborating with colleagues, and providing
best possible data and classification of HAI’s.
Staging Project
Considering evidence available it’s clear what needs to be done…
Timeline
Description
Feb 2011 • Where are we now with CLABSI, VAP and CAUTI
• How to prevent HAI’s?
• Literature and Tools available
• Are C-Diff and SSI’s important to us? How does antibiotic stewardship play a role?
April 2011 • HAI prevention campaigns
• Order sets available in most facilities
• Change management/Implementation
June 2011 • Prevention and surveillance methods, tools and resources
August 2011 • Finalize Toolkit
• Review change management
October 2011 • Measurement of progress
• Stakeholder analysis
December 2011 • Project status evaluation